THE Royal Flying Doctor Service of Australia (RFDS) was established in 1928 by the Reverend John Flynn, with the intent of providing a “mantle of safety” for the people in the bush. It has evolved from Hugh McKay’s early vision to fund an “aerial experiment” into a remarkable 24-hour, 7 days a week health service to enable people in rural and remote Australia, and who are beyond regular medical infrastructure, to access medical care in metropolitan-based tertiary hospitals. This includes a range of medical services and allows the RFDS to focus on emerging trends in health care needs.
Patients requiring definitive care in such hospitals are transported via a primary evacuation or interhospital transfer, both of which are referred to as “aeromedical retrievals”. With a fleet of 69 aircraft, operating from 24 aviation bases across all Australian states and the Northern Territory, the RFDS services 7.6 million square kilometres of our nation.
In 2018, this invaluable organisation celebrates its 90th year, and to date, the RFDS has been predominantly defined by its exceptional commitment to the provision of emergency care for rural communities.
What is less well known is that the RFDS has an extensive network of primary health care services, including general practice, medical specialist, mental health, nursing and dental health clinics, supported by a round-the-clock telehealth system. Moreover, what is even less known is that the RFDS is often the only organisation fulfilling the Commonwealth’s obligation of delivering universal access to health services to those patients who are limited by geographical isolation.
In looking to its 100th year, the RFDS now strives to ensure that as many health needs of rural Australians are met, emergent and basic. To inform its strategic direction over the next decade, the recently established RFDS’ Research and Policy Unit reviewed its aeromedical retrievals and episodes of patient contacts in the preceding 3 years.
It may come as a surprise to many that, from 2014 to 2017, more than 2000 patients from rural and remote Australia accessed the RFDS for neoplasms. However, even more surprising was that digestive system diagnoses ranked as the third most significant cause for RFDS patient transfers, just after diseases of the circulatory system, such as myocardial infarction, and injury or poisoning (ranked first). In that same time period, there were 71 323 separate patient transfers, with 2060 (3%) associated with cancer. Of those, malignant neoplasms of the digestive tract (18%), including colorectal cancer and hepatocellular carcinoma (HCC), led the RFDS’ list of aeromedical retrievals for cancer-related causes. Notably, bowel cancer and HCC are cancers that can be effectively screened for and prevented.
While the uptake of the National Bowel Cancer Screening Program is near equivalent between rural and remote Australia (42%) and major cities (39%), what follows is a critical cause for concern. Of those participants, people who live in remote areas have higher screening positive faecal occult blood test rates than those who live in cities (10% v 8%) but experience lower rates of further diagnostic follow-up or colonoscopy (54%) compared with city dwellers (73%). Patients who live in rural Australia also face significantly longer waiting times between positive screen and assessment. These disparities are thrown into greater relief by the 2015 Australian Atlas of Healthcare Variation, which revealed up to a 30-fold difference in colonoscopy rates between outer regional and remote Australia compared with some inner city precincts.
The incidence of HCC in Australia has escalated significantly to more than double in the past decade. Death from HCC has increased by more than 20% in Australia. However, there remains a paucity of data on HCC and cirrhosis rates in rural Australia by the Australian Government’s Institute of Health and Welfare, or the Australian Bureau of Statistics’ National Health Survey, and for the effectiveness of obesity and type 2 diabetes health literacy programs in rural communities.
Of Australians living in outer regional and remote areas, 70% are overweight or obese, and just as concerningly, 70% do not participate in exercise. Individuals who are obese or who have diabetes are at significantly heightened risk of several digestive tract cancers, including bowel, gastric, oesophageal and pancreatic cancers. Obesity and diabetes can interact with other risk factors for liver disease, such as chronic viral hepatitis infection or excessive alcohol, to further exacerbate HCC risk by up to 100-fold.
In a climate of federal budgetary restraint, financial uncertainty and political non-longevity, these health issues pose formidable challenges to rural families and for all who strive to provide them with optimal care.
Perhaps, we should derive inspiration from Lieutenant Clifford Peel, the airman and medical student who suggested the use of aviation to bring medical help to the Outback. Shot down in France, he died at the age of 24 years and never knew that his letter in 1917 to the Reverend Flynn was the cornerstone for the creation of what is now the RFDS. Perhaps, we should draw courage from the Services’ first pilot, Arthur Affleck, who flew in an open cockpit, exposed to the weather, had no in-flight aids, no radio and with only a compass, navigated by landmarks such as fences, rivers, dirt roads and telegraph lines.
The harsh reality of limited access to specialist gastroenterology, liver and cancer care will continue to challenge rural Australia into the next decade. Hence, more long term, bolder approaches as well as renewed and imaginative investment strategies are needed from several sectors beyond the Commonwealth’s. We should aspire to creating and promulgating health promotion activities that will prevent disease and disease complications and, thus, reduce demand for specialised services or aeromedical retrievals in the future: lifestyle modification, incentives to keep lean and fit, better uptake of cancer screening and novel initiatives to educate and to bring gastrointestinal and liver cancer screening to rural communities.
Here, new and less traditional partnerships should be explored between medical professional bodies and not-for-profit organisations that hold the health of rural people and their families close to their cores.
Consider a collaboration between the Gastroenterological Society of Australia with the RFDS, the Country Women’s Association and individual states and territories farmers’ organisations — we share a collective vision of good health and equanimity for those who live and work in the bush. There are many potential synergisms in working closely together towards the common aims of increasing the understanding of gastrointestinal and liver cancers, their predisposing factors and what simple, effective and positive preventive steps we can all partake in reducing such risks in our rural communities.
With new observations and data arising from rural-focused health promotion initiatives, the efficacy of cancer prevention interventions in rural Australia should be collected prospectively and analysed, and the findings should be used to shape future rural health policy and to leverage funding and support in kind.
In 2017 alone, the RFDS conducted 17 000 clinics across Australia, assisted 88 500 people by way of telehealth services and in the same duration, flew the equivalent of 34 trips to the Moon and back — astonishing feats of accomplishment by multiple teams working with and within the RFDS; tremendous human “horsepower” for harness towards the acute management and the prevention of disease in the air, and on the land over the next decade.
Congratulations RFDS on your 90th anniversary — wishing you many healthy, happy (aeromedical) returns!
Narci Teoh is Professor of Gastroenterology and Hepatology at the Australian National University and the Canberra Hospital. She is President of the Gastroenterological Society of Australia.
Lara Bishop is Director of Clinical Research at the Royal Flying Doctor Service of Australia.
Fergus Gardiner is the Manager of Research and Policy at the Royal Flying Doctor Service of Australia.